When patients take an active role in their healthcare, the results may be better, safer care. That is the premise behind the Ontario Hospital Association's (OHA) "Your Health Care - Be Involved" campaign. Launched in September 2005 by the OHA's Patient Safety Support Service, the campaign encourages active two-way communication between patients and providers and highlights the important role of patient involvement in the form of five patient safety tips. This article discusses the development, implementation and evaluation of Ontario's first-ever patient safety tips program, and what its future might hold.

Introduction

Patient safety consumer advocates in the United States have stressed the importance of consumer participation in the patient safety movement (Hatlie 2004). In October 2004, the World Health Organization launched the World Alliance for Patient Safety. One of the six action areas of the World Alliance is "Patients for Patient Safety" (PPS), a group designed to ensure that the perspective of patients and families helps shape the Alliance's work. PPS works from the premise that patients and their families have a meaningful role to play in patient safety, and that safety can be improved if they are included as full partners in reform (World Health Organization 2004).

Several jurisdictions have attempted to more fully involve patients in patient safety through the use of patient safety "tips" programs. The United States, the United Kingdom and Australia, as well as the provinces of British Columbia, Nova Scotia and Quebec, have used patient safety tips campaigns to convey safety messages to patients.

However, a recent article in the Joint Commission Journal on Quality and Patient Safety (Entwistle et al. 2005) has cautioned against the use of "consumer advisories" such as tips campaigns. The authors analyzed the development and content of five leading safety advisories and conducted 40 interviews with individuals from federal agencies and national organizations, researchers and consumer advocate groups. Concerns highlighted include the limited involvement of patients during development, missed opportunities to inform patients about patient safety practices and an uncertainty over how the advisory messages would be reinforced by providers. Another important concern was that advisories might be perceived as a shift of responsibility for safe care from providers to patient. Therefore, there is a need for campaigns to include better process development and evaluation components.

Campaign Development

The Ontario Hospital Association (OHA) is the voice of Ontario's hospitals. Since 1924, it has been a leader in shaping the future of the healthcare system, fostering excellence, building linkages with the community and advocating on behalf of its members for a sustainable system that meets patient care needs.

In June 2004, the OHA's Patient Safety Support Service (PSSS) was approached by Ontario's Ministry of Health and Long-Term Care (MOHLTC) to develop and implement a patient safety tips campaign that would increase Ontario healthcare consumers' knowledge of the role they can play in improving their health outcomes and their safety. The campaign, which would be the first of its kind in Ontario, would focus on patient empowerment and involvement through active, two-way communication between patients and providers. The campaign was to be province-wide, ongoing and accessible to the average Ontarian.

Despite the existence of materials and campaigns in other jurisdictions, both the concept and the specific messaging needed to be developed and tested for an Ontario patient and provider population. A list of 31 tips used in other jurisdictions was gathered and clustered under the following six topic areas: general patient safety tips, treatment, infection control, medication, falls avoidance and surgery.

Provider and patient focus groups were conducted in Toronto and North Bay. The purpose of the focus groups was to gauge reaction to the idea of a list of patient safety tips, and to isolate the top five tips that resonated most strongly with patients and would be accepted by the healthcare team.

These groups settled on the five tips that were most meaningful from their perspective. The specific wording of the tips was refined through a series of consultations with OHA members and provider associations such as the Ontario Medical Association, the Registered Nurses Association of Ontario and the Ontario Pharmacists Association. The final list of five tips was converted to a Grade 6 literacy level and translated into 13 languages.

Branding

"Branding" is a term used by advertisers to describe the process of packaging the essence of a product or concept in a few brief, memorable words. The branding strategy developed for the campaign was based on the findings of the focus groups and on the following principles:

• The desire not to brand the campaign as "patient safety," as this did not have much meaning for patients
• The desire to focus on patient involvement rather than on patients as guardians of safer care
• The desire to stress patient involvement as a member of a team rather than giving patients the impression that the onus for their care was being shifted to them
• The desire for the messaging to be applicable to hospitals as well as to the community sector

The campaign was branded "Your Health Care - Be Involved." A list of the tips is contained in Figure 1.

Campaign Elements and Media Strategy

The OHA developed a detailed, multipronged strategy to launch the "Your Health Care - Be Involved" campaign. The first prong, aimed at hospitals, consisted of several communiqués addressed to hospital administrators and communicators that shared campaign details and timelines. A slide deck was developed to assist hospitals with internal and external campaign messaging and promotion, and was included in a hospital tool kit designed to inform stakeholders about the internal rollout strategy.

The elements of the campaign included a brochure (containing information on all five tips, a tips wallet card and a patient information summary form), a large plaque-mounted poster (Figure 1), acrylic brochure holders and a four-minute DVD campaign "infomercial" for use during in-hospital television programming. All bilingual hospitals were sent materials in both English and French. Materials were sent to hospitals in advance of the campaign to give them the time to prepare, and to ensure the campaign was simultaneously launched in all Ontario hospitals.

The second prong of the campaign was to use the electronic and print media, as well as limited paid advertising, to promote the campaign to the general public. The campaign was launched at a press conference at the Toronto East General Hospital on September 13, 2005. Notices and materials were distributed to media outlets across Ontario, materials were made publicly accessible through the OHA website and articles about the campaign appeared in local media and health trade magazines. Paid transit-system advertisements were also used in 16 cities throughout Ontario.

The final prong of the campaign, which is ongoing, focuses on community outreach. As such, the OHA is actively working at spreading the campaign and reach by partnering with groups such as the Ontario Seniors' Secretariat and the Association of Ontario Health Centres. The OHA is also working with the Ontario College of Pharmacists and the Canadian MedicAlert Foundation to inform their members about the campaign.

Evaluation

The "Your Health Care - Be Involved" campaign was evaluated as part of an overall evaluation of the OHA's Patient Safety Support Service.

Methodology

The evaluation of OHA's Patient Safety Support Service was conducted over a three-month period by PricewaterhouseCoopers LLP (PwC). Data collection included a variety of qualitative and quantitative methods. Three focus groups (one for providers and two for patients), a Stakeholder Satisfaction Survey and a Patient Survey were designed to address the campaign.

All focus groups were conducted by PwC. The patient groups were designed to assess the awareness and impact of the tips initiative from the patient's perspective and to identify areas for improvement. Discussion questions included "Have you heard of the 'Your Health Care - Be Involved' campaign?," "Where have you heard about it?" and "Did you use any of the information and why?"

The provider focus group was tasked with assessing the impact of the campaign from the provider's perspective and identifying areas for improvement. Participants were recruited by telephone from a variety of locations across the province. Questions centred on the use and effectiveness of specific campaign elements and the overall successes and challenges.

The Stakeholder Satisfaction Survey was e-mailed to a group of stakeholders, the majority of whom are Directors of Patient Safety, Risk Management, Quality and Patient Relations. Participants were asked about their hospitals' tips dissemination strategy, the use and effectiveness of specific campaign elements and the overall effectiveness of the campaign.

The Patient Survey was an anonymous two-page self-report questionnaire designed to assess patient awareness and potential impact of the campaign. Research ethics approval was obtained from the Toronto Academic Health Sciences Network (TAHSN) Research Ethics Board. The six participating hospitals were recruited by telephone, and were sent English and French copies of the survey. Hospitals were asked to obtain a minimum of 20 completed surveys over a two-day period in June. Facilities were instructed to distribute the survey to patients in ambulatory clinic waiting rooms and to patients awaiting discharge on the day of survey administration. A total of 108 surveys were completed.

Patients were asked about campaign awareness and its impact on their communication with their healthcare team.

Results

Providers

Hospitals distributed the brochures in several locations including clinics (47%), patient resource centres/libraries (23%), admitting packages (28%), waiting rooms, lobbies, nursing units and common patient areas. Hospitals used a number of methods to promote the campaign internally and externally, as follows:

• Discussion at staff meeting (54%)
• Inclusion in hospital newsletter (44%)
• Posting on hospital website (21%)
• Article in local newspaper (14%)
• Advertisement in local newspaper (2%)
• Other methods (18%)

Although the campaign has only been in place for 10 months, two-thirds (66%) of stakeholders rated it "very effective" or "somewhat effective." Providers noted several positive outcomes as a result of implementing the campaign. They felt that the initiative was very helpful in reminding staff that patient care and safety is the hospital's core business. Many believe that the campaign provided the opportunity for patient safety discussions at the senior management and board level; that it supported the hospital's patient safety and patient satisfaction programs; and that it was a simple, focused way to encourage hospital staff to focus on patient safety. Providers also felt that the initiative was well received by staff, particularly the concept of patient empowerment, and that new staff were impressed that the hospital "really cared" about patient safety. These benefits were viewed as positive and unexpected wins.

The concern most commonly cited by providers and patients was what they saw as the excessive length of the brochure. Respondents indicated that this, and the brochure's layout, limited cost-efficient hospital reproduction.

Patients

Findings from the patient focus groups suggest that while awareness of the campaign was low, patients were supportive of the five Patient Safety Tips.

The findings from the survey provide interesting insight into campaign awareness and impact. As reported in Table 1, patients were asked a series of questions about their communication with the healthcare team during their last visit to hospital. The results suggest that the majority of patients are communicating with their healthcare team in a manner consistent with the Patient Safety Tips. However, there is room for improvement in communicating information about medications (27% of patients did not bring their medications, or a list, to the hospital) and discharge instructions (16% did not know what to do once they left the hospital).

The survey also found that awareness of the "Your Health Care - Be Involved" program was not very high (Table 2). The results below indicate that only 17% of patients surveyed had heard about the program. The remaining survey questions were only asked of patients who were aware of the campaign and consequently the sample size is substantially smaller and is a limitation of this survey.

The best method of informing patients about this campaign was through the hospital rather than through the limited media campaign (Table 3). Nearly one-half of patients who were aware of the campaign saw the brochures or posters in hospitals.

In terms of usage of the elements of the campaign, one-third of respondents reported using the brochure and 14% used the summary form (Table 4).

Of the patients who were aware of the campaign, the majority felt the brochure was easy to understand (77%), relevant (59%), helpful (63%), practical (75%) and available in their preferred language (75%).

To gauge the impact of the Patient Safety Tips on patients, patients were asked whether they had changed the way they communicated with their health team as a result of the Tips. There were only 15 responses to the question. Of those, almost half (47%) of the respondents indicated that they had changed the way they communicated with their health team as a result of having the "Your Health Care - Be Involved" information (Table 5).

Discussion

Evidence of Success

From the OHA's perspective, the campaign has been highly successful. The OHA continues to receive requests for campaign materials from hospitals and community agencies across the province and across Canada, with a recent request for materials from the Yukon. To date, over 60 hospitals have requested additional supplies and 10 community organizations have requested their first shipment of materials. As community agencies were not involved in the original campaign, their interest and requests for materials speaks to the value and spread of the campaign.

Other, anecdotal evidence of campaign success includes the numbers of "hits" and downloads on the website and the requests for conference presentations and posters. The Patient Safety Support Service section of the OHA website and the patient safety tips subcategory continue to be some of the most active program areas. The campaign has been recognized nationally by the Canadian Patient Safety Institute (2006) as being "one of the most comprehensive collections of patient safety tips, available in 14 languages." Recently, the OHA has received a request from a US publisher to reprint campaign materials in a guidelines manual to highlight "wonderful patient safety tools" from around the world.

The results from the PSSS evaluation indicate that both patients and providers are interested and enthusiastic about this type of campaign. Hospitals used and promoted the materials provided. Two-thirds of providers feel the campaign was effective or at least somewhat effective. Of particular interest are the "side benefits" providers report, such as the campaign fostering internal organizational discussions about patient safety and reinforcing existing patient safety programs. As with many patient safety initiatives, these "side benefits" are equally important in fostering a culture of safety.

Among patients, awareness of the campaign was low, which may be a result of a number of factors such as hospital dissemination strategy, the small media campaign and other competing hospital initiatives. However, patients seemed genuinely interested in and supportive of the initiative.

The results indicate that, while a large majority of patients surveyed already follow some of the behaviour suggested by the tips, there is still room for improvement in the areas of medication communication and discharge instructions. Of the patients who were aware of the campaign, the majority reported that they found the information useful and relevant.

Changing behaviour is challenging. Awareness of the Patient Safety Tips campaign was modest, and in light of the limited sample size, it is difficult to come to any conclusion about campaign impact on patient behaviour.

Key Learnings

Many key learnings have emerged from both the development and evaluation of the Patient Safety Tips initiative. One of the most important is that patients are ready to accept and use this type of information.

Other lessons learned include the importance of seeking upfront commitment from hospitals and healthcare providers. As the campaign focused on information-sharing and asking questions of healthcare providers, and relied on these individuals to promote and disseminate the information, it was essential to educate providers on this initiative prior to the launch. Leadership was also required within hospitals so staff and patients could see this as a priority.

Consultation and partnerships aid in project development. Messages should be tested with the target audience and stakeholders to ensure the validity of the messages used in the campaign. Partnerships help to find creative ways of distributing materials to patients.

Rigorous evaluation of a community awareness campaign can be difficult. As patient safety has become a priority for Canadian hospitals, it has become increasingly challenging to parse out the impact of any one initiative. It is also challenging to evaluate an awareness and education campaign in a quantitative way, especially given that so little time has elapsed since its inception.

Conclusion

The OHA's experience in launching the "Your Health Care - Be Involved" campaign demonstrates the interest among patients for easily understandable information about their role in their healthcare. The OHA is considering further refinement of selected campaign tools on the basis of information received through the evaluation. Although the five tips can be applied in some form to most healthcare sectors, they were developed with specific reference to the acute care sector. The OHA has recently received requests for sector-specific campaigns - since different patient populations have different needs - and the OHA is also exploring the need, interest and feasibility of a pediatric tips initiative.

Patient safety efforts in Canada have to a large extent focused on the system and system improvements, while very little attention has been paid to patients' roles. Patients do have the potential to influence their own health outcomes if they are actively involved in their healthcare. They also have the desire to be more active participants in their care. As Canada moves forward in our patient safety journey, it will be essential to make a more concerted effort to involve patients.

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